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Prediction of Postpartum Depression: Take a Closer Have a look at Query 3 on the PHQ-9

Previous studies have indicated that poor sleep quality while pregnant is related to increased risk for postpartum depression (PPD), in addition to more severe depressive symptoms. Given this association, could the endorsement of sleep problems on routine depression screening questionnaires be used to discover women at increased risk for PPD?

While many obstetric practices are actually screening for depression while pregnant and the postpartum period using standardized questionnaires, a lot of the attention is concentrated on the endorsement of depressive symptoms and whether or not the whole rating exceeds a specified cutoff number. Each the Patient Health Questionnaire-9 item (PHQ-9) and the Edinburgh Postnatal Depression Scale (EPDS), instruments commonly used to screen for perinatal depression, ask about sleep problems. While sleep disturbance is usually related to depression, it is a symptom that is just not typically analyzed individually.

A recent study from Felder and colleagues looked more closely at sleep disturbance reported on depression screening questionnaires administered while pregnant in an effort to evaluate whether sleep disturbance was predictive of postpartum depressive symptoms amongst non-depressed pregnant individuals.

On this retrospective cohort study, participants were included in the event that they had a live birth and accomplished the Patient Health Questionnaire (PHQ-9) while pregnant and inside 8 weeks postpartum. A complete of three,619 participants who were non-depressed while pregnant (PHQ-9 < 10) were included within the evaluation. 

In individuals without depression, endorsement of sleep disturbance within the second and third trimesters was related to a greater than threefold higher odds of postpartum depressive symptoms, adjusting for age, race, ethnicity, and parity (second trimester sleep disturbance aOR 3.74, 95% CI 1.47–11.49; third trimester sleep disturbance aOR 3.43, 95% CI 1.88–6.78), followed by an almost twofold higher odds for endorsement of sleep disturbance in the primary trimester (aOR 1.90, 95% CI 1.17–3.13).

Sleep disturbance varied by race through the first and second trimesters (p < 0.05) and was highest amongst Black or African American participants (61.8–65.1%). Third trimester sleep disturbance had a stronger association with elevated postpartum depressive symptoms (aOR 3.43) than did the opposite somatic symptoms (fatigue aOR 2.24; appetite disturbance aOR 2.15). 

Clinical Implications

The findings of the present study are consistent with the present literature indicating an association between sleep disturbance while pregnant and increased risk for PPD. Sleep disturbance within the second and third trimesters was related to a greater than threefold increase in risk of postpartum depressive symptoms (aORs 3.74 and three.43, respectively). This study indicates that even a single-item measure of sleep disturbance has utility in prospectively identifying risk for postpartum depression prior to delivery.

What’s so vital about this and other studies taking a look at the connection between sleep disturbance and risk for PPD is that sleep disturbance is a modifiable risk factor. Especially when identified early within the pregnancy, we’ve got the chance to intervene. 

In a randomized controlled trial, Manber et al (2019) observed that 64% of pregnant participants who received cognitive behavioral therapy for insomnia (CBT-I) experienced symptom remission. There’s also evidence that digital adaptations of CBT-I could also be effective while pregnant (Felder et al, 2020; Kalmbach et al, 2020). Moreover, there may be preliminary evidence to point that sleep interventions delivered while pregnant may decrease risk for postpartum depression. 

Ruta Nonacs, MD PhD


Felder JN, Roubinov D, Zhang L, Gray M, Beck A. Endorsement of a single-item measure of sleep disturbance while pregnant and risk for postpartum depression: a retrospective cohort study. Arch Womens Ment Health. 2023 Jan 12.

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